Diary from a Week in Practice

Am Fam Physician. 1998 May 1;57(9):2116-2120.

Monday

“Has Dr. Hartman been putting Clomid in the coffee maker again?” inquired a curious patient after hearing the news that SEF was expecting twins. One could certainly wonder what the chances are of two female physicians in a small practice each having twins. Recent data have shown that the frequency of fraternal twinning in the overall population is about one in 50 live births, but identical twinning is much rarer and does not seem to be affected by the same factors. These factors include race, mother's age and obstetric history, genetics and treatments for infertility. Twins occur with decreasing frequency in the black, white, Hispanic and Asian populations, respectively. An increased rate of twinning occurs in older mothers as well as in multiparous mothers. Genetics show us that there may be an inherited trait on the maternal side that contributes to an increase in twin births, but there is no compelling data to suggest that the same is true for the father's side. Of course, the influence that has probably most affected the incidence of twins remains infertility treatment. SEF and TBS have found that sometimes the most important factor is simply the luck of the draw.

Tuesday

We often hear of a physician's influence on the actions of his or her patients. CAG experienced this first hand recently. In treating one of JRH's patients who had an ingrown nail on the great toe of the right foot, CAG had excised the nail edge and ablated the edge of the nail bed using an electrocautery unit. It was the first time he had used the unit for this procedure, and he was looking forward to seeing the long-term outcome. The patient did well after the procedure but did not return for follow-up. Six weeks later, when CAG thought he had again crossed paths with this patient in the hallway, he asked if he could examine the patient's right foot. The man obediently sat down and removed his shoe and sock to reveal a healthy great toe that had never been cut. To CAG's embarrassment, he realized that this was not the same patient. After CAG apologized to the patient, the man smiled and said that he was pleased to meet one of the new doctors, although a simple handshake would have sufficed!

Wednesday

Congratulations are in order to a group of physicians involved in the British Family Heart Study who published their findings in the July/August 1997 issue of Archives of Family Medicine (p. 354). The study measured the extent to which changes in cardiovascular risk factors were correlated in married couples. It involved over 1,400 men and their female partners in 13 primary care centers in Great Britain. The fabulous part of the study is that it looked at “family health check-ups.” Its outcome measures were one-year changes in cigarette smoking, systolic blood pressure, serum cholesterol levels, glucose levels and total coronary risk score. The results demonstrated that men and women who benefit most from risk factor reductions have partners who also tend to benefit. Conversely, men and women who enjoy little or no benefit have partners who tend to have similar smaller benefits. Therefore, it demonstrated what most family physicians know, “that lifestyle intervention targeted at couples (and families) rather than individuals results in greater reduction in cardiovascular risk factors.” The researchers hypothesized that this occurred “possibly through mutual reinforcement of lifestyle changes.” Certainly, to family physicians in the field this is merely proof of the obvious. However, it is additional proof, at least to us, that family medicine is the best medicine.

Thursday

The fun of delivering babies never grows old. Today, JSR received a call from the labor and delivery unit at about 3 p.m. One of his multiparous patients was in active labor with regular uterine contractions and a reassuring fetal heart rate pattern. Labor was allowed to progress and, at 5 p.m., he received a follow-up page telling him that his patient was completely dilated and ready to deliver. JSR hurried to the hospital just in time to deliver a beautiful baby girl. He tended to the mother and baby and, by 6 p.m., was at home eating dinner with his family. The next morning as JSR was sharing the story of this “timely” delivery and how wonderful it felt to be with a young family at this special time in their lives, JRH commented with a twinkle in his eye, “Now, why don't all family physicians deliver babies?”

Friday

Having partners around has many benefits for sharing knowledge. This is particularly true when it comes to reading x-rays. Like many of you, we read some of our films ourselves and send some of them out for over-reads. In the latter case, we find it useful to quiz ourselves before the official report returns. Today, JRH asked SEF for her opinion on whether the x-ray changes on a patient's right hip are those of avascular necrosis. There did seem to be a positive crescent sign, and there was some loss of sphericity and some increased density in the femoral head from probable bone collapse, but still JRH was surprised that all of this could be occurring in such a normal-appearing 15-year-old person. “Don't be so surprised, John,” SEF said. “Oh?” JRH replied, hoping for some pearl to add to his collection. “These films are my patient, and he's 60 years old!” quipped SEF. Today, JRH learned that knowledge sharing comes in the most fundamental forms.

Saturday/Sunday

WLL was involved in an Internet discussion with family physicians around the country about the evaluation and management guidelines mandated by HCFA. Toby Acheson, M.D., summed up the sentiments of most of the others by observing, “I slogged through the new HCFA documentation requirements. I give the talks to the residents and faculty to educate them about these guidelines. I try to simplify things, give examples, and I get blank stares in return. The (mostly) unstated messages are: ‘Has the world gone mad?’ What has this got to do with good patient care? Bad doctors will just make up stuff to fill up the page and charge more for worse care than good doctors who don't document all the unimportant negatives and will undercharge out of fear. The tail is wagging the dog! We should be going the other way: there should be fewer levels of visits to choose from, with simpler documentation requirements. Is anyone at HCFA correlating the documentation data with patient outcome data, or is it a joke to discuss HCFA and patient well-being in the same breath? My hope is that private physicians will rebel, stop seeing patients, complain to whoever will listen, especially important lobbying groups such as the AARP (I am a member!). My retired FP friends, who, by the way, gave excellent care reflected in their concise chart documentation and wise choice of tests, referrals and medications, miss their interactions with long-term patients, but are so glad they aren't dealing with the ever more complex bureaucracy which they feel permeates, perturbs, permutes and poisons the patient-physician relationship.”